Special Edition of Medicine Chest: Detection and Treatment of Depression

Depression is not unique to any individual or group. Depression can affect the mind, body, mood and behavior of anyone. As in the general population, some HIV-positive patients are at higher risk for clinical depression. Patients with a previous history or family history of depression are at higher risk, as well as those who are dealing with alcohol or substance abuse. Women also are at higher risk, as compared to men.

How do you know if you are experiencing clinical depression or just having a bad hair day? Symptoms of depression include changes in sleep patterns, changes in eating habits, loss of interest in activities, excessive or inappropriate guilt, lack of energy or motivation, inability to concentrate, apathy, agitation, depressed mood, and suicidal thoughts. Most experts agree that to be considered clinically depressed, at least five of these symptoms must be present all day for at least two weeks, and include either a lack of interest in activities or depressed mood as one of the symptoms. Studies indicate that depression is somewhat difficult to diagnose in people living with HIV/AIDS. Many of the symptoms of depression like fatigue, appetite changes, or problems sleeping can resemble manifestations of HIV. Some opportunistic infections like toxoplasmosis, cryptococcal meningitis and HIV-related dementia, as well as medications used to treat opportunistic infections can affect one's mood or ability to function normally. Antiretroviral drugs can have side effects causing agitation, depressed mood (e.g., AZT/Retrovir), or sleep disturbances (e.g., Sustiva). For these reasons, healthcare providers must be careful in determining if depression in clients is being caused by medical or drug-related issues.

Like HIV disease, depression has stigma attached to it. Seeking help and discussing problems openly is uncomfortable for most people. Even people who have support systems and excellent healthcare benefits may refuse or be reluctant to seek assistance for depression because of perceived stigma. For this reason, many people turn to self-medication to help deal with feelings of depression.

It is important to be aware that some substances -- including alcohol, cocaine, ecstasy, crystal and ketamine -- that people use to help cope with depression can exacerbate the condition. In addition, withdrawal from alcohol will have depression-like symptoms. While street and party drugs can provide temporary escape from depression, they can also accelerate progression of HIV disease. Herbal and over-the-counter remedies can help treat depression, but may have unwanted drug interactions with antiretroviral drugs.

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If not treated, depression can impact the course of HIV disease. Stress and depression can result in a slight decline of CD4+ T-cells and compromise the body's immune function. Depression can also cause apathy, self-neglect and forgetfulness that may result in poor adherence to antiretroviral drugs and complementary therapies.

Nonetheless, there is hope for individuals living with HIV/AIDS who are also coping with depression. Treatments are available to reduce symptoms of depression and improve the quality of life. Psychotherapy (counseling), pharmacotherapy (drugs) and a combination of both are the standard of care. However, the goal of medication -- prescription and alternative -- used to treat depression is intended to return you to "normal" rather than make you numb to your feelings.

The most common class of drugs used for depression today is called SSRIs (selective serotonin re-uptake inhibitors). Drugs in the SSRI class include Prozac, Paxil, Zoloft, Luvox, Celexa, and Anafranil. Sexual side effects are common with some of these drugs, and may include delayed orgasm, problems getting an erection, and decreased interest in sex. When people are depressed, a decreased interest in sex is not uncommon. If the antidepressant drugs are effective, the sexual side effects may subside. Viagra does seem to help reduce the erectile problems caused by the antidepressant drugs. Cyclic antidepressants are also used today to a lesser extent. These drugs include amitryptyline (Elavil), nortriptyline and doxepin. Amitriptyline is also used to treat peripheral neuropathy. Sedation, dry mouth and constipation are often seen as side effects with cyclic antidepressants. Wellbutrin, Serzone, Effexor and Remeron are other drugs effective in the treatment of depression in HIV-positive individuals. Wellbutrin (buproprion, Zyban) may be prescribed to help stop smoking. Weight gain often occurs with antidepressants, but can be a welcomed side effect.

Treatment of depression with prescription drugs in HIV may be slightly different then in the general population mainly due to possible drug interactions with the antiretroviral therapies. Most of the antidepressant drugs are safe to take with antiretrovirals with a few exceptions. Ritonovir (Norvir) and Lopinavir/r (Kaletra) may increase blood levels of Wellbutrin. This interaction may lead to increased risk of seizures and should be used with caution. Other side effects include insomnia, agitation, or sedation. This can get confusing because depression itself causes these problems.

Because all of these drugs have side effects, your doctor may need to try different combinations to find one that is both effective and free of unwanted adverse effects. It is important to communicate any benefits and problems you experience to your healthcare provider, so that they may be able to fine-tune your treatment. Talk to your physician or healthcare provider if problems get worse or are difficult to adapt to. Antidepressants are usually started at low doses and then increased as necessary. In most cases, improvement of side effects and benefits of these drugs can take between two-to-six weeks before full effect can be assessed. After six months of successful results, your provider may want to discontinue the medication. If depression reoccurs, the drugs can be restarted.

Other drugs can also be used to improve feelings of well being in depressed individuals. Stimulants like methylphenidate (Ritalin) and androgens like testosterone can be prescribed. Benefits include more rapid results and fewer side effects over antidepressant drugs. Androgens can help put weight on patients who have wasting syndrome. However, stimulants can also cause unwanted weight loss and anxiety. As with any form of therapy, talk with your physician or healthcare provider before taking any medication for depression.

Glen Pietrandoni is director of Clinical Pharmacy Services for the Walgreen Specialty Pharmacy, focusing on HIV, located in the Howard Brown Health Center of Chicago.

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